The USPSTF reaffirms its recommendation for screening of all pregnant women for syphilis

The US Preventive Services Task Force (USPSTF) today reaffirmed its 2009 recommendation for early screening of all pregnant women for syphilis following a massive surge of cases of congenital syphilis. The statement was published September 4 in the JAMA with an accompanying editorial in JAMA Dermatology.

The newest guidance is a class ‘A’ recommendation which means that there exists substantial evidence in favor of the benefits of early screening for mother and fetus. 

Vertical transmission of syphilis can occur any time and at any stage during pregnancy, and congenital syphilis is associated with adverse outcomes such as preterm birth, low birth weight, stillbirth, congenital anomalies, active syphilis in the newborn (NB) and long-term health sequelae such bone deformities and neurologic impairment.

In the US, the incidence of congenital syphilis has increased by nearly 87% between 2012 to 2016, after a steady decline during the previous 4 years.  The rise coincides with rising national rates of syphilis among women of reproductive age – from 0.9 cases of primary and secondary syphilis infection per 100,000 women in 2012 to 1.9 cases in 2016.

The USPSTF recommends that all pregnant women should be screened for syphilis as early as possible when they present at the healthcare provider’s office. If a woman presents directly in labor and has not received any testing earlier, she should be immediately tested.

The screening test for syphilis is a two-step process– initially a “nontreponemal” antibody test (i.e., Venereal Disease Research Laboratory test or rapid plasma reagin [RPR] test) is done to detect biomarkers released from damage caused by syphilis infection, followed by a confirmatory “treponemal” antibody detection test (i.e., fluorescent treponemal antibody absorption or T pallidum particle agglutination test).

A newer alternative is a reverse sequence screening algorithm that involves an automated treponemal test (such as an enzyme-linked, chemiluminescence, or multiplex flow immunoassay first, followed by a nontreponemal test.

The CDC has recommended parenteral benzathine penicillin G for the treatment of syphilis in pregnant women. Evidence in favor of the safety of alternative treatment is limited; therefore, women who present with an allergy to penicillin should be evaluated and desensitized first and treated with the drug.

One way to decrease the incidence of congenital syphilis is to bring down the rates of primary and secondary syphilis infection among all women. Lower rates of syphilis in women prevent the sexual transmission and subsequent vertical transmission of congenital syphilis. Hence, the USPSTF recommends screening for syphilis in nonpregnant adolescents and adults at increased risk for infection.

The current recommendations are in accordance with those issued by other professional organizations. The CDC recommends screening for syphilis infection in all pregnant women at their first contact with the provider. The CDC, AAP, and ACOG also recommend repeat screening at 28 weeks of gestation and again at delivery in women who are at high risk for syphilis infection.

High-risk women include those with HIV or a history of incarceration or commercial sex worker. ACOG and AAP also recommend repeat screening after encountering an infected partner.

JAMA Full article

JAMA Dermatology editorial

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FDA clears easy to use, low-cost Luminelle DTx Hysteroscopy/Cystoscopy system in the US

UVision360's, a Raleigh, N.C.-based company announced that its Luminelle DTx hysteroscopy system used for performing both hysteroscopy and cystoscopy won FDA clearance for sale in the US.

The Luminelle DTx Hysteroscopy System is simplified, easy to navigate, fully integrated hysteroscopy system designed for benefits for patients and physician alike.

It enables the physician to perform diagnostic and operative procedures in the office with 75% less investment as compared to traditional endoscopy tower systems. Patients can rip the benefits of faster procedural and recovery time along with cost savings.

The system features a two-part single-use protective sheath consisting of the introducer and 360° Rotating sheath. The introducer thoroughly covers the scope thereby protecting it against bodily fluid and reducing contamination to the minimum. It also separates the inflow and outflow channels to manage the irrigation fluids. The operative channel enables biopsies and polypectomies under direct visualization.

The 360° Rotating sheath facilitates ease of movements and 360° view of the uterine cavity. The flexible 2.0 mm scope is equipped with the latest CMOS micro-technology for a high resolution, high definition view of the inside of uterus and bladder to a depth of 45-55 mm. Specially designed visualization software comes with auto-adjusting lighting for more comfortable viewing of cavities.  The whole procedure can be monitored via HDMI or USB 3 for PC or Mac systems, making use of systems already existing in the office.

Dr. Amy Garcia, MD FACOG; Director – Center for Women's Surgery; Institute for Hysteroscopy Training, Albuquerque, NM explains, "Since the best technology is typically only available in the operating room, many physicians and patients opt to skip the hysteroscopy and either perform a blind biopsy or go straight to surgery, without taking a good look inside of the uterus. An in-office system that is easy to use prevents a blind biopsy and allows the physician to offer either a therapeutic diagnosis or a biopsy under visualization elevates the standard for uterine care."

Allison London Brown, CEO of UVision360 said in a news release, "Most operating room equipment is cost and space prohibitive for standard office use. We created an elegant and ergonomic system with visualization quality comparable to that of the OR, and that is comfortable for both physician and patient."

"Our system is a fully-integrated hysteroscopy/cystoscopy system with a value-based cost to provide better accessibility for the changing needs of today's GYN. The combined features lead to the potential for better care for women, earlier detection, and improved health outcomes," she further added.

Product overview

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Hyperemesis gravidarum does not usually recur in each pregnancy

Women who have suffered from Hyperemesis gravidarum can now be reassured that severe morning sickness does not necessarily recur in each pregnancy according to the results of the study published August 16 in the American Journal of Obstetrics & Gynecology.

The Finnish study provides evidence that 3 out of 4 women who suffered from hyperemesis gravidarum will not experience it in the subsequent pregnancy. The incidence of hyperemesis is 0.5-2.0% and is the most common cause of first-trimester hospital admissions.

The exact etiology of hyperemesis is still unknown, and both maternal and paternal genetics, family history and environmental causes have all been implicated in its causation. Hyperemesis recently hit the headlines when Kate Middleton, the Duchess of Cambridge and wife of Britain's Prince William, was hospitalized with hyperemesis gravidarum during her first pregnancy.

Finnish researchers identified 1836 women over a period of 7 years who were diagnosed with hyperemesis during their first pregnancy and who had at least one more subsequent delivery. The first pregnancy with hyperemesis was considered as an index pregnancy, and the recurrence rate was calculated based on the incidence of hyperemesis and the total number of subsequent pregnancies. 

There were 2,267 later pregnancies, of whom hyperemesis occurred in 544 or 24% of pregnancies, while in 1723 pregnancies no morning sickness was noted. In case of more than 1 subsequent pregnancy, 333 (11%) of women suffered from hyperemesis in all of their pregnancies.

Women who were second para during the index pregnancy were 33% more likely to suffer from hyperemesis as compared to those who were para one (adjusted odds ratio, 1.33, P = .046).

Being overweight and smokers were at decreased odds of recurrence of hyperemesis in subsequent pregnancy. Women with female fetuses were also at 29% increased odds of recurring hyperemesis (adjusted odds ratio, 1.29, P = .012).

Miina Nurmi, lead author of the study, told Reuters Health by email, “It is good to know that hyperemesis gravidarum (HG) is not a ‘lifelong sentence’ to everyone - sometimes HG patients have been told that HG would be with them in every pregnancy.”

 “It is reassuring to know that hyperemesis does not appear to become more likely with each pregnancy and that after 1 pregnancy with hyperemesis, the following pregnancy may be different,” the authors concluded, admitting that comparison of recurrence is difficult given the lack of universal definition of hyperemesis gravidarum.

The authors further suggested that "Large prospective studies concentrating on HG patients' future pregnancies, studied with both symptom diaries and medical records, would be an ideal way, though slow and somewhat expensive, to come as close to the actual recurrence rate as possible."

Abstract

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